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Advanced Clinic Massage shared a post:How does yoga compare with other forms of exercise?The short answer is: It depends on the type of yoga.See more by reading the below article and learn how you can achieve yoga health benefits, benefits of yoga and meditation, yoga definition, and benefits of yoga in the morning.

Christophe Haubursin

I read more than 50 scientific studies about yoga. Here's what I learned.

I’m a yogi. I'm also a skeptic. Sometimes I wonder if the two can go together. I cringe whenever an instructor claims I'm "wringing the toxins" out of my organs with a twisting pose, for instance. Still, after eight years, I keep going back. Post-yoga, I feel calmer and more aware of my body, and this seeps into everything I do: how I work and relate to others, how I eat and sleep.

The bottom line

What we know:

Yoga is probably just as good for your health as many other forms of exercise. But it seems particularly promising for improving lower back pain and — crucially — reducing inflammation in the body, which can actually help stave off disease. Yoga also seems to enhance "body awareness," or people's sense of what's going on inside themselves.

What we don't know:

Whether some forms of yoga are better than others, whether yoga should be prescribed to people for various health conditions, and how yoga compares with other forms of exercise for a good many specific health outcomes. There's also no good evidence behind many of the supposed health benefits of yoga, like flushing out toxins and stimulating digestion.

What this means for you:

If you like yoga, keep doing it. There's no evidence that it's particularly harmful, and it can lead to a range of heath benefits. Depending on your goal, it's important to find an appropriate style — from athletic ashtanga to gentle hatha. If you don't like yoga, no sweat: Just try another physical activity.

Welcome to Show Me the Evidence, where we go beyond the frenzy of daily headlines to take a deeper look at the state of science around the most pressing health questions of the day.

It's not just me.

The most recent survey suggests more than 20 million Americans practice yoga, making it one of the most popular forms of exercise. Even Vladimir Putin, a devotee of "macho sports," added downward dog to his repertoire.

But is yoga really that great for health compared with other exercises? Does it really help improve our response to stress or correct bad posture, as often promised? Maybe our perceptions about yoga are biased. Or maybe, as some critics have pointed out, there are downsides to yoga. Who can forget the controversialNew York Times story from 2012 suggesting that some people get seriously injured, or even die, on their yoga mats.

I wanted a more objective view on the health effects of yoga, so I turned to science, reading more than 50 studies and review articles and talking to seven of the world's leading yoga researchers. Almost immediately, I was struck by how weak the research on yoga is. Most studies were small and badly designed or plagued by self-selection bias. Making matters worse, there are so many varying styles of yoga that it's tough to say how meaningful evidence about one style is for others.

Still, what I learned is that there are a few things we can say about yoga, based on the available research. Yoga probably won't hurt you, despite what haters claim, and it appears to be just as good for your health as other similar forms of exercise.

Even more, yoga seems to help alleviate lower back pain, improve strength and flexibility, and reduce inflammation in the body — which, in turn, can help stave off chronic disease and death. Emerging research suggests yoga can increase body awareness, or attention to the sensations and things going on inside you. That's no small matter: Researchers think heightened body awareness can improve how well people take care of themselves.

Keep in mind, however, that other mind-body exercises — such as tai chi or meditation — can boost body awareness and reduce inflammation, too. That's the catch with a lot of yoga research: It still hasn't told us how much better or different yoga is for a number of health measures when compared with other forms of exercise. Finally, many of the most outlandish claims people make about yoga, like the idea that it can alleviate constipation or wring out toxins, either aren't backed by science or haven't been studied at all.

What is the state of yoga science?

(ChinaFotoPress/Getty Images)

The first randomized trial (or high-quality experiment) on yoga was published in 1975 in The Lancet. It showed that yoga was more effective than relaxation for reducing high blood pressure. But that trial only involved 34 participants, and all of them already had high blood pressure, so it is difficult to know whether the effect of the yoga would bear out in a larger trial of healthy people.

Since then, the number of yoga studies has dramatically increased, but the field is plagued by some of the same problems of that early study. Many yoga studies still involve small numbers of participants. Many lack a control group. Many don't compare yoga to activities we'd be interested in comparing it to. (Ideally, for instance, we'd want to know how yoga measures against another form of exercise or mind-body practice — not, as one study examined, comparing whether it's better for back pain than giving people a book on how to manage their back pain.)"For most conditions, the main problem is we don't have enough evidence yet"

What studies do exist are often short term. There are no long-term studies on mortality or serious disease incidence. There are few long-term studies on the potential harms yoga can wreak on the body. "For most conditions," says Holger Cramer, director of yoga research at the University of Duisburg-Essen in Essen, Germany, "the main problem is we don't have enough evidence yet."

More from Show Me the Evidence

Studying yoga is also tricky. Researchers generally believe blinded studies are the highest quality of research, because participants involved don't know what intervention (such as a drug) they are receiving and their biases and perceptions don't color the outcomes. But you can't blind people to the fact that they're doing yoga.

Then there's the biggest question at the center of yoga research: How do you define yoga? "Yoga is many things to many people," said Karen Sherman, a researcher affiliated with the Group Health Research Institute. "What you put into a yoga intervention probably impacts what you get out."

Yoga usually involves some combination of the following: postures and poses (asanas), regulated breathing (pranayama), and meditation and relaxation (samyana). But many classes mix in other elements, from chanting to heating to music. There's also a lot of variation in teaching quality and style. Hatha and Iyengar yoga are mostly made up of stretches and restorative poses, while ashtanga and vinyasa tend to be more vigorous and athletic. Yin yoga probably won't make you sweat: You mostly hold postures for long periods of time for very deep stretches. In Bikram, which consists of 26 postures repeated twice in a room that's heated at 105 degrees, you can be sure you'll drench your yoga clothes in perspiration.

(Soloviova Liudmyla/Shutterstock)

Lorenzo Cohen, chief of the integrative medicine section at MD Anderson Cancer Center, told me: "Many papers [on yoga] don't have enough of an in-depth description of what they mean by 'yoga.' What was the level of training of yoga therapists? How did they choose different postures or breathing exercises?"

What's more, there are so many components in a yoga class, it's tough to know what might be having an affect on health: If people report feeling better after a class, was that due to the experience of being part of a larger group? Was it the teacher's style? Was it the breathing exercises? The heat? These factors are difficult to isolate, and some of the ways yoga helps people might be hard for scientists to measure.

Still, the yoga researchers I spoke to said the quality and quantity of studies has been improving, so we may get better answers soon. "There are more researchers conducting yoga therapy studies, and when the smaller trials suggest benefit, that leads to larger, better-designed trials," said Cohen. There is also a move to study the biological outcomes of yoga — how classes affect things like hormone levels — which will lead us to a more objective picture of what yoga can do for the body.

1) Is yoga likely to hurt you?

No, probably not.

This question first came up in 2012, when the New York Times published a splashy article suggesting that yoga can wreck your body. The piece, adapted from the book The Science of Yoga: The Risks and Rewards, suggested yoga caused widespread harm to its practitioners — from ruptured disks and stroke to brain injury.

But that piece was largely based on cherry-picked anecdotes, exaggerating these horrible cases to suggest they were representative of the broader yoga experience when they simply aren't.

(Luna Vandoorne/Shutterstock)

Cramer has studied published reports of injuries and other harms from yoga for several review and told me this: "We found yoga is as safe as any other activity. It's not more dangerous than any other form of exercise." He added: "Yoga is not 100 percent safe, but nothing is 100 percent safe."

In a 2013 review of case studies, Cramer identified 76 unique incidents of adverse events from yoga. "Most adverse events affected the musculoskeletal, nervous, or visual system," he concluded. "More than half of the cases for which clinical outcomes were reported reached full recovery, 1 case did not recover at all, and 1 case died."

Most often, people got into trouble with the headstand pose, followed by shoulder stand and postures that required putting one or both feet behind the head

Most often, people got into trouble with the headstand pose, followed by shoulder stand, postures that required putting one or both feet behind the head, the lotus position, and forceful breathing. Pranayama-, hatha-, and Bikram-style yoga practices had the most adverse events associated with them.

Based on these cases, Cramer and his co-author had this practical advice for how to stay safe in yoga: Beginners should avoid advanced postures (such as headstands), and people with chronic health conditions (such as glaucoma) should consult their doctors before diving in. "Yoga," they added, "should not be practiced while under the influence of psychoactive drugs."

As for long-term yoga harms, Cramer pointed to two studies on joint and cervical disc degeneration in people who have been doing yoga for a while. But the studies had contradictory results, "so long-term health consequences cannot be clearly derived from the available evidence," Cramer said.

I asked MD Anderson's Cohen for his take. "There can, of course, be negative consequences if done incorrectly, like any body manipulation," he said, "but if you have the right teacher this will not happen." Even if a lot of yoga over a lifetime leads to injury, it's not clear those harms outweigh the benefits, or that people would have been better off running or weightlifting all the time.

2) How does yoga compare with other forms of exercise?

(Anna Furman/Shutterstock)

The short answer is: It depends on the type of yoga. Yoga classes that involve nothing more than lying around on piles of blankets and breathing aren't likely to build your muscles. But more strenuous types of yoga like ashtangacan be surprisingly similar to other forms of vigorous exercise.

"Some studies show, depending on yoga style, that it doesn't improve fitness as much as other forms of exercise," Cramer says. "But for rigorous and intense styles [of yoga] — that can be a form of exercise. It strongly depends on what you do when you do yoga."

For example, a few high-quality studies have shown that certain types of yoga can indeed make people stronger. One small, randomized trial in the Journal of Strength and Conditioning Research — which compared eight weeks of Bikram yoga with no intervention in 32 young, healthy, adults — found that the yoga classes improved people's deadlift strength.

The Bikram classes didn't, however, improve the participants' aerobic capacity.Another before-and-after study, published in the Journal of Clinical Nursing, found that hatha yogacould improve aerobic fitness in older people. Still, it's not clear that yoga is ideal here compared with, say, running or swimming.

Considering the mixed findings, a bit of common sense is helpful: If you go to a class mainly focuses on relaxation and doesn't elevate your heart rate, you're probably not getting a good cardio workout or building muscles.

If you go to a more athletic yoga class that tires out your muscles and makes you pant, you can probably count on it helping to make you stronger. If you are panting in a yoga class, you're probably improving aerobic capacity to some extent. That said, if your main goal is building aerobic capacity, you might want to try running or swimming instead of or in addition to yoga.

Key studies:

1975: Lancet — "Randomised controlled trial of yoga and bio feedback in management of hypertension." This is the first-ever randomized trial on yoga, and it found that yoga was more effective than relaxation in reducing high blood pressure.

1985:British Medical Journal— "Yoga for bronchial asthma: a controlled study." This is the first randomized trial on yoga for asthma, and it was one of the first to show the effects of yoga on the inner organs.

1998:JAMA — "Yoga-based intervention for carpal tunnel syndrome." This was a well-regarded randomized trial that showed the benefits of yoga for carpal tunnel syndrome compared with wrist splinting and no intervention.

2005: Annals of Internal Medicine — "Comparing yoga, exercise, and a self-care book for chronic low back pain." This is the most important trial on yoga for lower back pain and the first really high-quality trial on yoga. Based on this trial, yoga had become increasingly recognized as an effective treatment for chronic lower back pain.

2013: Journal of the American College of Cardiology — "Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation." One of the first trials to show that yoga may have an impact on life-threatening diseases such as atrial fibrillation.

2014:Journal of Clinical Oncology— "Randomized, controlled trial of yoga in women with breast cancer undergoing radiotherapy." This high-quality trial demonstrated yoga can have benefits for women being treated for breast cancer.

2015: Brain, Behavior, and Immunity — "Mind-body therapies and control of inflammatory biology." A review of the evidence on yoga and other mind-body activities, and their relationship to reducing inflammation.

3) Does yoga really reduce stress and anxiety?

For all the talk of yoga lifting moods and calming people, the studies on this question are still surprisingly inconclusive.

Karen Pilkington, a research fellow at the University of Westminster, knows this research better than anybody: She sifted through the science for systematic reviews on yoga for both anxiety and depression. (Here's another, more recent systematic review of the evidence on yoga for depression by other authors.)

"There are indications that it might be helpful," Pilkington says. "But lots of the studies are quite small, and we definitely need more and bigger studies." In other words, yoga might help with mood disorders, but we don't yet know for sure because the studies to date have generally been so badly designed. "We can't say there’s conclusive evidence that yoga works for depression and anxiety," she explained. "We’re still really exploring yoga as an idea for testing and the best ways of testing it."

One complication here: When it comes to conditions like anxiety and depression, it can be difficult to untangle whether it's the yoga that's helping or simply the act of going out, joining a group on a regular basis, and so on. Even if yoga turns out to be unequivocally beneficial for depression, other research has shown that exercise in general can alleviate depression. So, again, it's not clear that yoga is the only way to get this benefit.

As for stress reduction, there are a few randomized trials — the highest-quality evidence — that have suggested yoga is about as effective as simple relaxation programs, more helpful than no intervention, but not as effective as stretching. Pretty mixed results.

4) Does yoga have long-term health benefits?

Possibly. To be clear, there's currently no direct evidence on yoga's long-term benefits. Researchers simply haven't tracked yogis over a span of 20 years or more and followed up to see whether they get diseases at a lower rate than non-yogis.

How can this be? One possibility is that yoga can help reduce inflammation in the body — which turns out to be surprisingly beneficial.

You can think about inflammation in two ways. There's helpful inflammation, as when your body's immune system mounts a response to bacteria in a cut. There's also harmful inflammation.When you're stressed, your body's inflammatory response can go into overdrive, hampering its ability to fight off viruses and disease. People who are inactive, obese, or eat an unhealthy diet have higher levels of harmful inflammation. And researchers have found associations between inflammation and various chronic diseases, including cancer, cardiovascular disease, and diabetes.

Yoga — like other mind-body exercises such as tai chi and meditation — seems to be particularly helpful at reducing harmful inflammation. A 2014 meta-analysis on the effects of mind-body therapies on the immune system found that yoga reduces inflammation-based blood markers. So did this 2014 randomized control trial looking at women with breast cancer and breast cancer survivors.

Michael Irwin at UCLA's medical school, one of the authors of a 2015 descriptive review on inflammation and mind-body exercises, said, "When you look at the aerobic exercise necessary to decrease inflammation, people have to maintain very vigorous levels." But not with yoga, he continued. "Even practices with minimum levels of physical activity [like Iyengar stretches] can have large effect sizes." Researchers don't yet know why, though they think the meditative components of yoga, tai chi, and meditation may have something to do with it.

"When you compare long-term yoga practitioners to people doing other forms of exercise, you have better body awareness in yogis"

In the past few years, some academics have also begun to study "body awareness" and its relationship to a number of health outcomes. Body awareness, according to this article in PLOS One, "involves an attentional focus on and awareness of internal body sensations." The idea is that in becoming more aware of your body, you might be more likely to notice when you're stressed, in pain, or tired, and perhaps less likely to abuse your body.

This 2013 study, involving 18 people with chronic neck pain who practiced Iyengar yoga once a week for nine weeks, found that participants reported increased body awareness after practicing. In this 2005 study, which compared three groups of women — 43 doing Iyengar and ashtanga yoga, 45 doing aerobic exercise, and 51 who did neither activity — the yogis reported more body awareness and body satisfaction than the other groups. These were both qualitative studies, not experimental trials, so it's difficult to know whether the yogic types are more "body aware" to begin with or whether the yoga made the difference.

"When you compare long-term yoga practitioners to people doing other forms of exercise," said Cramer, "you have better body awareness in yogis."

[There's] found strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness of yoga for chronic low-back pain in the most important patient-centered outcomes. Given the low number of adverse events, yoga can be recommended as an additional therapy to patients who do not improve with education on self-care options.

That said, there are some caveats here, too. The leading researcher on this question, Karen Sherman, notes that it's still not clear whether yoga is any better than any other form of exercise for back pain. "It’s certainly a viable form of exercise, but is it better than other exercises [for back pain]? Probably not," she says.

Some of the best research on lower back pain has only looked at one specific type of yoga — viniyoga.

Researchers haven't figured out why yoga helps with back pain. This Cochrane Review protocol offered a few guesses, suggesting that improved flexibility and muscle strength, as well as relaxation and body awareness, may help.

7) Can yoga really stimulate digestion or wring out toxins?

Anyone who has taken a yoga class has probably been exposed to wild claims by the teacher that certain poses will do anything from wring out toxins to stimulate a particular part of the colon and alleviate constipation. But the science backing up these kinds of very specific claims was scant, so I asked one of the researchers, Cohen, about where they come from.

"[Teachers are] basing it on personal experience, on anecdote, on the lineage of practice that's been handed down," he said. "They are probably not basing it on Western-style analytic techniques that followed a control trial design. We just haven't gotten there yet with yoga research, testing particular poses or breathing techniques for particular outcomes."

Preterm Infant Massage Outcome Measures

According to the review, the most common outcome measure in these studies was weight gain among the preterm infants.

Other outcome measures assessed in the published research included sleep, calorie consumption, bilirubin levels, vagal activity, number of stools, heart rate variability, pain and length of hospital stay, among others.

As for the interventions used in these studies, the authors of the review state that, in most cases, the preterm infants were assigned to either a preterm infant massage group or a standard-care control group.

However, several of the studies compared other touch-based interventions, such as massage with and without oil or massage versus light, still touch.

Although there was some variation in the type of massage used during these interventions, the analysis showed that most of the studies involved tactile-kinesthetic stimulation (TKS) for the preterm infants, as well as modified versions of TKS.

“Modifications of TKS included shorter or longer duration of massage, as well as elimination of kinesthetic range of movement exercise with only tactile stimulation provided,” the authors report.

“Other massage types evaluated include oil massage combined with either TKS or other standardized technique, Vimala massage, and acupressure and meridian massage.”

In terms of the specific effects of massage on preterm infants, analysis of the 34 studies revealed a positive effect on weight gain, as well as an increase in vagal tone.

The authors of the review point to the increase in vagal tone as a potential driving force behind the beneficial weight gain associated with massage for preterm infants.

“More studies are needed on the underlying mechanism of the effects of massage therapy on weight gain in preterm infants,” state the authors of the review.

“While some trials suggest improvements in developmental scores, decreased stress behavior, positive effects on immune system, improved pain tolerance and earlier discharge from the hospital, the number of such studies is small and further evidence is needed.”

That statement is from Tiffany Field, PhD, director of the University of Miami's Tough Research Institute.

Dr. Field says this of the 2004 study.

"You don't get those brain-waves changes and the heart-rate slowing and people being in a more relaxed state in light-pressure massage."

Dr. Field adds that these studies didn't compare the length of massage-therapy sessions.

"All I can say is that you won't get the effects unless you use moderate pressure,"

"I don't think the routine is as much of an issue as moderate pressure."

"We've done 10 minutes, a half hour, 15 minutes. That doesn't seem to be a factor."

The New Coffee Break

By: Pete Reinwald

Marilyn Kier knew the stresses of the workplace. As a business consultant for 15 years, she knew the aches in the fingers, the tightness in the shoulders, the pain in the neck. She knew she needed to bring wellness to the workplace.

She joined the chamber of commerce in Northbrook, Illinois, with the idea of sitting chamber members down and showing them what they'd been missing.

"I went there with my massage chair, and everybody looked at me like, 'Is she serious?'" Kier says. You bet she was. She still is. About 10 years later, Kier maintains a core group of about 12 companies, and others seasonally, with which she maintains relationships in the art and income of workplace- or corporate- massage.

"I had no trouble getting into any corporation from large companies like Motorola to smaller privately owned companies," Kier says. No formal studies have been done on trends, but some say corporate massage has leveled off since its 1980s mainstream introduction by TouchPro Institute founder David Palmer, known by some as the father of contemporary chair massage.

Others say it continues to boom. They cite an increasing number of therapists offering workplace massage and an increasing number of companies welcoming it with open and aching arms. "There's so much potential business out there," says Denver therapist Julie Wallace. "I get very excited when I see it becoming accepted as a mainstream idea as a wellness practice."

Says therapist Linda Dumbrigue of Novi, Michigan: "I think there is a huge untapped market, and that's why it's an interest to me." Dumbrigue is among the therapists looking for ways to tap into it. Therapists who have had success securing relationships with companies say it usually comes down to a lot of hard work, homework and creativity-and sometimes, a little luck.

Gary Jones of Austin, Texas, says he once was doing chair massage at a public event-and the CEO of a local company sat down in his chair. "She said, 'Can you come to my company?' I happened to be in the right place at the right time."

Hard work and Homework

Kier sent out flyers to all members of the Northbrook, Illinois Chamber of Commerce. She also joined a local group called the Worksite Wellness Council of Illinois, in which businesses would vie for an annual wellness award. The businesses would attend meetings on wellness in the workplace-and Kier made sure she attended as well. Before she knew it, Kier was bidding on contracts for seated massage.

"I'd determine what their goals and needs were, and I would come back with a proposal on how I could help them achieve that," Kier says.

Jason Miller of Enfield, Connecticut, and his partner, Kevin Zorda, spent $1,500 on newspaper ads trying to attract corporate interest to chair massage. They didn't get one call back. They knew they had to try something different. That's when they started thinking outside the box-literally.

They got a four-inch-by-four-inch box. They decorated each side with either words or illustrations that trumpeted their service. One side had an illustration of somebody receiving a chair massage. Another side showed a testimonial from a previous client. Another side included research on employee and company benefits. The top featured just four words: Think outside the box.

"It helped us stand out from the crowd," Miller says. "And it showed a little uniqueness. We'd get a call: 'That's kind of funny. You think outside the box.'"

They'd not only get a call, Miller says. They'd get a client. Miller and other massage therapists-who have been successful in workplace massage-say they can't emphasize enough the importance of the planning and work that go into securing and maintaining corporate accounts. They say therapists should be aware of the time involved in each account, some of which can take up to a half a day or a full day of work, including travel and setting up. That doesn't include communication and coordination leading up to each corporate visit and administrative duties such as billing and collections.

Successful therapists also point out that expanding into corporate massage can mean hiring and training additional therapists.

"You have to decide whether you want to be the business owner or the massage therapist," Kier says. Kier, owner of Wellness At Work, says she wants to remain a therapist. She says she scaled back on her corporate business, which "kind of runs itself now" on the strength of independent contractors whom she trained. "I personally am focusing on orthopedic massage and pain management," she says.

Kier says her background as a corporate consultant helped her to understand "all the stresses that might occur" within the workplace. Her company website (www.wellnessatwork.net) cleverly reads: "Kier, a nationally certified massage therapist who has a BA in psychology, spent 15 years working in employee benefits consulting before she switched gears and became an employee benefit."

But if a business background is helpful, a business plan is essential. Therapists should know the market, the time and money involved in winning a share of it, the resources involved in maintaining it, and the financial results therein. Kier says she uses the same business plan she wrote in massage school-a 60-page paper that features her ethics, policies, principles, operations and more. Once their financial plans are in order, therapists are ready to go after a piece of this vast and seemingly growing corporate pie.

Going for It

Therapists agree on the need for an "inside advocate," somebody inside the company who sees a need for company-wide massage therapy. Wallace, the Denver therapist, says she introduces herself to companies at which she knows somebody, so her foot is in the door and the ice is broken. She sometimes offers her contact a free 20-minute massage as another ice-breaker.

Miller says he and Zorda have their own method: they go straight to the top. "We seek the head honcho of the company," he says. Firstly, he says, it saves time by eliminating red tape. Secondly, it helps the therapist to better educate the company on corporate chair massage. "We found that many of the CEOs were war veterans and were used to the type of massage they got overseas," Miller says. As a result, he says, many corporate executives continue to perceive massage only as "dim lighting, soft music, on a table, sedated." His company, Connecticut Chair Massage, had to break the "corporate massage myth," he says. "We had to educate the clients." Massage schools are doing their part, too. Zorda, director of the massage therapy program at the Windsor, Connecticut, campus at the Branford Hall Career Institute, says his program offers a 30-hour course that focuses exclusively on seated massage. The course covers marketing, networking, price-setting and more.

"We often tell [students] that there's networking groups that they can get involved with," says Zorda, also a massage therapy evaluator for the Accrediting Council for Independent Colleges and Schools. "We're close to Hartford, and we have a lot of insurance companies and a lot of banks," he says. Therefore, they emphasize network groups that might be connected to those types of industries.

Selling It

Once inside the company door, Denver's Wallace produces a one-page sheet that explains what employees can get from her 20-minute chair massage, that employees keep their clothes on and that they won't be coated with oil or lotion, since neither are used. More importantly, Miller says, therapists must emphasize to prospective clients the ultimate advantage of workplace massage. "They don't care about how it's going to increase blood flow," Miller says. "They care how it's going to improve the bottom line, how it's going to enhance productivity."

Miller says he makes sure he's familiar with studies on workplace massage, such as those done by the University of Miami's Touch Research Institute, which show a correlation between massage, alertness and lower anxiety. "We show them studies," Miller says. "There's just limited research out there on workplace massage," he adds.

Kier points out, though, that much more is being written about massage in general-that more doctors are prescribing it, that people are using it not only as a luxury but to manage pain and that more insurance companies are beginning to pay for hour-long massages. Therapists who arm themselves with such articles can enhance their sales pitch. Kier says she is quick to speak at organizations about the benefits of massage.

She once was asked to be a massage spokeswoman of sorts at a Northwestern University conference on holistic health. "The more you can align yourself with other professionals who look at massage as a credible health benefit," she says, "the more I think that credibility and professionalism will generate corporate arrangements."

Pricing It

Therapists say they use a $1-per minute rule of thumb as a basis for corporate deals. Jones says he uses a tiered pricing system by which he charges $60 per hour if he's providing massages at the company for 3½ hours or more. If he's at the company for fewer than 3½ hours, he charges $70 per hour. "I charge a higher rate for less time," Jones says. "It's expensive getting out there and setting up." He requests a gratuity on one-time arrangements. "I've found that whenever I've charged it, people don't balk," he says. He waives the gratuity as an incentive to establish a regular relationship with the company.

Company arrangements vary from once or twice a week, to once a month to once a year, to whenever the mood and the money strike the company. Sometimes the employees pay for the massages; sometimes the company pays for them, and some-times the employees and company share the costs.

Of 18 corporate accounts maintained by his company, Miller says, 11 are paid entirely by employees, two are paid entirely by the companies and five are partially paid for by the companies. When employees are paying for all or part of the massages, therapists say, it's a good idea to have the employees pay in advance. The therapists thereby know they have a commitment and know how many therapists to send to the job. When the company pays all the costs, the therapist generally knows the frequency of company-wide sessions (once a week, once a month, etc.). In such cases, some therapists ask the company to let them know ahead of time how much time will be needed on the coming visit, and they bill the company in advance.

Doing It

As with most chair massage sessions, workplace-massage sessions generally last 15 to 20 minutes, focusing on the neck, head, back, shoulders, arms, hands and fingers. Most therapists prefer to customize each session, as if to say to the employee: "I care about you, not just your company." Many ask the client whether they have any areas that need special attention. They ask new clients about health history, recent injuries and whether they've had chair massage.

Kier says she trains her independent contractors to focus on individual needs. "Our goal is to really customize the on-site massage on what each employee needs on any given day that we're there," she says. "It's not just a routine. These are skilled therapists who can ask questions and tailor the session accordingly."

"We encourage all of our staff to individualize each session," Miller says. "If you're doing the same routine over and over again, you're really not helping anyone." Jones says his teacher required all of his therapists to execute at least a variation of the same chair-massage routine, adapted from an Eastern style of therapy called shiatsu that emphasizes energy channels and pressure points.

"Everybody has his or her own interpretation of that routine," Jones says. "They kind of make it their own. The routine that I use has a certain flow to it. I might leave out some things and just focus on the things that people like, if somebody requests something specific."

The key is for the company and employees to feel comfortable with the therapist. Take it from Briefing.com, a Chicago-based company that provides financial news and analysis. The company sought a massage therapist "driven by a sense of ergonomics and keeping employees healthy," says Pat O'Hare, manager of investor content at Briefing.com.

The company started with one visit a week from a therapist. It's now up to two visits a week. The company and employees share the costs. Employees there feel good about their therapist, O'Hare says. More importantly, they just feel good.

"She's become kind of like one of us at Briefing.com," O'Hare says of the company's therapist. "She's a friendly face-and a nice face to see twice a week. We're glad that she understands that we put in a lot of hours and do a lot of sitting and staring at a computer."

A few Things to Know

Your chair. "We did a large event one time in conjunction with about 40 other therapists…and many were not trained in how to perform chair massage or even how to adjust the chair. That had a huge impact on clients who had never had a chair massage before." -Jason Miller

Your client. "I think what makes any therapist successful is to be able to establish that rapport on a nonverbal basis. They get an impression of you in a matter of seconds. If you don't connect with them, you might not get another chance. You have to do everything you can to establish that rapport quickly and do everything you can to make them feel comfortable." -Marilyn Kier

Your boundaries. "When things change, what are you willing to do and not willing to do? The owner of a company, at the last minute, called to cancel the chair massage gig. I said, 'OK, I do expect payment,' even though I didn't work. I had blocked out that time, and I wasn't going to fill that time on short notice." -Gary Jones

Your business arrangements. Companies that pay 100 percent of the massage costs make for convenient and seemingly stable, but not necessarily long-term, business arrangements. When the employee pays all or part of the cost of the massage, "they seem to see more value in the massage. Those who do it because the company pays for it don't always see the value right away." Also, "when companies are trying to cut the budget, that's the program that gets hit relatively quickly." -Kevin Zorda

Your business potential: "It's a very rare occasion that somebody receives a chair massage and doesn't become a repeat customer." -Julie Wallace

Studies: Moderate Pressure is the Key

Studies by the University of Miami's Touch Research Institute underscored the power of workplace massage.

A 1996 study published in the International Journal of Neuroscience showed that massaged adults exhibited enhanced mental alertness, completed math problems in significantly less time and with more accuracy, and exhibited lower job stress levels after a five-week period.

A 2004 study, also published in the International Journal of Neuroscience, showed that anxiety scores decreased for all groups who received moderate massage (an indentation in the skin), light massage (light stroking) and vibratory stimulation-but that the group receiving the moderate pressure displayed the greatest decrease in stress.

"We found that moderate pressure was the key," Tiffany Field, PhD, one of the leaders of both studies, says of the 2004 study. "You don't get those brain-waves changes and the heart-rate slowing and people being in a more relaxed state in light-pressure massage."

Field says the studies didn't compare the length of massage-therapy sessions. "All I can say is that you won't get the effects unless you use moderate pressure," she says. "I don't think the routine is as much of an issue as moderate pressure. We've done 10 minutes, a half hour, 15 minutes. That doesn't seem to be a factor."

I had three good reasons for getting a chair massage:

I was getting ready to write an article about it;

I had $18 in my pocket-enough for a $15, 15-minute massage and a small tip;

I was getting nagged by my back and shoulders, which were telling me: "If we don't start feeling better soon, you're in big trouble." So I visited a therapist after work one day in downtown Chicago. The therapist took my coat and my glasses and told me to have a seat on the chair. I sat down on the chair but wasn't quite sure what else to do. I gingerly rested my chin on the doughnut-looking pad at the top. My eyes looked inquisitively toward the ceiling. My feet were on the floor, my arms at my sides. I felt uncomfortable. And I felt goofy. Said my back and shoulders: "You're killing us."The therapist, who apparently had assumed that I knew what to do with my head, hands, feet, knees, back and chin, gently and patiently directed me into position, and we were ready to go.She started by touching my back lightly, sweeping both hands in what felt like figure-eights. It relaxed me, and I liked it. She then really went to work, applying moderate pressure to my back, neck and shoulders. It wasn't doing much for me. It felt as though her hands and my relief were slipping away.After a few minutes, the therapist told me that she couldn't seem to work through my dress shirt. It was 60 percent cotton and 40 percent polyester-apparently great for killing both wrinkles and massages. I took off my overshirt, and the therapist quickly found what she told me was a trigger point in the upper left side of my back. It was a sign of some sort of repeat activity, she said. I thought about it, and she was right: For months, I'd been carrying a heavy work bag-always on my left shoulder-to and from my commuter train.Her revelation prompted me to adjust the load in my bag and to occasionally switch shoulders, and her work made the pain go away. I also liked the attention she gave my arms and fingers.I knew the session was coming to a sad, but soothing, end when she reverted to light touches and figure-eights. She concluded with a couple of light, little taps as if to say: "Atta boy. You finally listened to your body."Attribution: https://www.amtamassage.org/articles/3/MTJ/detail/1654/the-new-coffee-break

A review of 80-plus studies upends the conventional wisdom.

Cathryn Jakobson Ramin’s back pain started when she was 16, on the day she flew off her horse and landed on her right hip.

For the next four decades, Ramin says her back pain was like a small rodent nibbling at the base of her spine. The aching left her bedridden on some days and made it difficult to work, run a household, and raise her two boys.

By 2008, after Ramin had exhausted what seemed like all her options, she elected to have a “minimally invasive” nerve decompression procedure. But the $8,000 operation didn’t fix her back, either. The same pain remained, along with new neck aches.

The big takeaway: Millions of back patients like Ramin are floundering in a medical system that isn’t equipped to help them.They’re pushed toward intrusive, addictive, expensive interventions that often fail or can even harm them, and away from things like yoga or psychotherapy, which actually seem to help. Meanwhile, Americans and their doctors have come to expect cures for everything — and back pain is one of those nearly universal ailments with no cure. Patients and taxpayers wind up paying the price for this failure, both in dollars and in health.

Thankfully, Ramin finally discovered an exercise program that has eased her discomfort. And to this day, no matter how busy her life gets, she does a series of exercises every morning called “the McGill Big Three” (more on them later). “With very rare exceptions,” she says, “I find time to exercise, even when I’m on the road.”

More and more people like Ramin are seeking out conservative therapies for back pain. While yoga, massage, and psychotherapy have been around for a long time, there was little high-quality research out there to understand their effects on back pain, and doctors sometimes looked down on these practices. But over the past decade, that’s changed.

To learn more, I searched the medical literature on treatments for lower back pain (the most common type) and read through more than 80 studies (mainly reviews of the research that summarized the findings of hundreds more studies) about both “active” approaches (yoga, Pilates, tai chi, etc.) and passive therapies (massage, chiropractics, acupuncture, and so on). I also talked to nine experts and researchers in this field. (For more detail on our methods, scroll to the end.)

What I found surprised me: Many of these approaches really do seem to help, though often with modest effects. But when you compare even those small benefits with the harm we’re currently doing while medically “treating” back pain, the horror of the status quo becomes clear. “No one dies of low back pain,” one back pain expert, University of Amsterdam assistant professor Sidney Rubinstein, summed up, “but people are now dying from the treatment.”

Mainstream medicine has failed people with chronic back pain

Lower back pain is one of the top reasons people go to the doctor in the US, and it affects 29 percent of adult Americans, according to surveys. It’s also the leading reason for missing work anywhere in the world. The US spends approximately $90 billion a year on back pain— more than the annual expenditures on high blood pressure, pregnancy and postpartum care, and depression — and that doesn’t include the estimated $10 to $20 billion in lost productivity related to back pain.

Doctors talk about back pain in a few different ways, but the kind most people (about 85 percent) suffer from is what they call "nonspecific low back pain." This means the persistent pain has no detectable cause — like a tumor, pinched nerve, infection, orcauda equina syndrome.

About 90 percent of the time, low back pain is short-lived (or in medical lingo, “acute”) and goes away within a few days or weeks without much fuss. A minority of patients, though, go on to have subacute back pain (lasting between four and 12 weeks) or chronic back pain (lasting 12 or more weeks).

Chronic nonspecific back pain is the kind the medical community is often terrible at treating. Many of the most popular treatments on offer from doctors for chronic nonspecific low back pain — bed rest, spinal surgery, opioid painkillers, steroid injections — have been proven ineffective in the majority of cases, and sometimes downright harmful.

Here’s the outrageous part: All these opioids were being prescribedbefore we actually knew if they helped people with chronic lower back pain. It gets worse: Now high-quality evidence is coming in, and opioids don’t actually help many patients with chronic low back pain.

This soon-to-be-published randomized controlled trial was the first to compare the long-term use of opioids versus non-opioid medications (such as anti-inflammatory drugs and acetaminophen) for low back pain. After a year, the researchers found opioids did not improve patients’ pain or function, and the people on opioids were actually in slightly more pain compared to the non-opioid group (perhaps the result of “opioid-induced hyperalgesia” — heightened pain brought on by these drugs).

As for surgery, only a small minority of patients with chronic low back pain require it, according to UpToDate, a service that synthesizes the best available research for clinicians. In randomized trials, there was no clinically meaningful difference when comparing the outcomes of patients who got spinal fusion (which has become more and more popular in the US over the years) with those who got a nonsurgical treatment.

Steroid injections for back pain, another popular medical treatment, tend to have similarly lackluster results: They improve pain slightly in the short term, but the effects dissipate within a few months. They also don’t improve patients’ long-term health outcomes.

It’s not entirely surprising that the surgeries, injections, and prescription drugs often fail considering what researchers are now learning about back pain.

Historically, the medical community thought back pain (and pain in general) was correlated to the nature and severity of an injury or anatomical issue. But now it’s clear that what’s going on in your brain matters too.

“Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role but psychological and social factors also play a big role," Roger Chou, a back pain expert and professor at Oregon Health and Science University, summarized.

For example, when you compare people with the same MRI results showing the same back injury — bulging discs, say, or facet joint arthritis — some may experience terrible chronic pain while others report no pain at all. And people who are under stress, or prone to depression, catastrophizing, and anxiety tend to suffer more, as do those who have histories of trauma in their early lives or poor job satisfaction.

The awareness about the role psychological factors play in how people experience pain has grown more widespread with the general shift away from the dualist view of the mind and body toward the more integrated biopsychosocial model. Chronic nonspecific low back pain “should not been considered as a homogenous condition meaning all cases are identical,” researchers in one review of the research on exercise cautioned.

A new understanding of pain called “central sensitization” is also gaining traction. The basic idea is that in some people who have ongoing pain, there are changes that occur between the body and brain that heighten pain sensitivity — to the point where even things that normally don’t hurt are perceived as painful. That means some people with chronic low back pain may actually be suffering from malfunctioning pain signals.

Enter alternative therapies for chronic back pain

Despite the clear risks, doctors have continued to prescribe painkillers, and perform surgeries and injections, sometimes to patients who won’t take no for answer or who can’t afford to try alternatives (which usually aren’t covered by insurance plans).

Slowly, though, the tide is shifting.

Medical societies and public health agencies are now advising doctors to try less invasive options and even alternative therapies such as acupuncture before considering opioids or surgery.

At the same time, research has mounted suggesting active therapies (exercise programs, yoga, tai chi) can really help people work through back pain, and alternative approaches (massage, spinal manipulation) can be effective, too — with the caveat that they’re often no panacea and the effects tend to be short-lived and moderate.

But most of the alternatives also carry little or no harm (except to patients’ pocketbooks) — which makes them all the more appealing amid the historic drug crisis.

“We have a slew of modalities and procedures that the American College of Physicians cannot endorse — such as opioids, fusion surgery, such as injections,” Ramin said, because there’s now so much evidence of ineffectiveness or harm. “So all those things are off the table, and now they are looking for things they can endorse that will not cause harm.”

Moving is probably the most important thing you can do for back pain

When back pain strikes, your first instinct may be to avoid physical activity and retreat to the couch until the pain subsides.

But doctors now think that in most cases, this is probably the worst thing you can do. Studies comparing exercise to no exercise for chronic low back pain are consistently clear: Physical activity can help relieve pain, while being inactive can delay a person’s recovery.

Exercise is helpful for a number of reasons: It can increase muscle strength, which can help support the spine; It can improve flexibility and range of motion in the back, which can help people’s functional movement and get them back to their normal living; it can boost blood flow to the soft tissues in the back, which promotes healing and reduces stiffness. These are just a few reasons why researchers who study back pain suggest opting for exercise before some of the passive therapies like acupuncture or massage (we’ll describe those later).

Researchers in this 2016 review of the research on exercise for chronic nonspecific low back pain summarized exercise’s range of benefits, including these pretty amazing findings:

“Aerobic exercise for 20 min on a cycle ergometer at 70% peak oxygen uptake reduced the pain perception for more than 30 min for patients with [chronic low back pain].”

“Improving the flexibility of the lumbar spine and hamstrings can significantly reduce [chronic low back pain] by 18.5%–58%.”

“Core stabilization programs have been shown to significantly reduce [chronic low back pain] by 39%–76.8%, and a muscular strength program significantly reduced [back pain] by 61.6%.”

Those researchers suggested that a combination of exercises — strength training, aerobic exercise, flexibility training — may be most helpful to patients, and that there seemed to be no clear winners among the different approaches but that each had its own benefits.

“My general take,” Chou said, “is that all [exercise types] seem to work.” If people find a program that makes them feel better, he added, they’ll probably see benefits not only with their back but with their overall health and sleep patterns, too.

To be clear, exercise doesn’t always help with those short-lived acute episodes. But if you have chronic back pain, you’ll want to find ways to work through the discomfort and keep active. Next, we’ll turn to some more specific exercises that are popular (and well studied) for back pain.

Yoga, Pilates, and tai chi seem to help — but it’s not clear that they’re any better than other exercise

There’s lots of research on back pain and yoga. Not all of it is high-quality, but taken together, the evidence pretty uniformly suggests yoga can both decrease pain and improve back-related function. (You can read more about yoga’s health benefits — and the difficulties of studying the practice — in this Show Me the Evidence.)

The most recent Cochrane systematic review on yoga and chronic low back pain, published in 2017, sums up the results of the best available studies, which mostly focused on the Iyengar, Hatha, or Viniyoga forms of yoga:

There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance.

So again, this isn’t an end-all treatment — but the evidence we have points in the direction of a benefit.

Importantly, the review authors also noted that it’s not clear whether yoga is better than other exercises, since there were few head-to-head comparisons tracking yoga against other kinds of workouts.

As for tai chi and Pilates, the Agency for Healthcare Research and Quality (AHRQ), a federal agency that crunches the best available data on the effectiveness of health care interventions, recently published a comprehensive 800-page systematic review of research on noninvasive treatments for low back pain, including these two kinds of exercises. It found tai chi seemed to reduce chronic back pain and help people return to their daily activities when compared with no exercise, and that it was more effective in alleviating pain than backward walking or jogging but not necessarily better than swimming.

For Pilates, the evidence was a little more mixed: It was associated with small or no effects on pain and no effects on function compared with other types of exercise. Again, though, pretty much every back expert I spoke to said any exercise is better than no exercise, so if Pilates is something you enjoy, do it.

Try to find a “back whisperer,” or try these three exercises from one

Ramin, the journalist and author of Crooked, makes a compelling argument for seeking out a specialist who deeply understands the back to tailor an exercise program that targets your specific pain.

These “back whisperers” come from many different backgrounds: doctors of physical therapy with an orthopedic clinical specialist certification, personal trainers with a degree in exercise science, physical therapists.

“They are able to observe how you walk and sit and stand, and grasp what your posture and gait say about your muscles, tendons, and ligaments,” she writes in Crooked. “Generally, they focus on functional training, prescribing exercise regimens that are ‘non-pain-contingent’ (you don’t stop when it hurts, sorry), ‘quantitative’ (you will not be allowed to quit until you hit your ‘number’), and ‘high-dose’ (you will do this routine on a schedule rather than when the spirit moves you).”

One renowned “back whisperer” isspine biomechanics professor Stuart McGill, of the University of Waterloo in Canada, who has treated everyone from Olympic athletes to professional football players. He spends several hours watching his patients move, and identifies the specific motions, postures, and loads that trigger their back pain. He then tailors exercise programs that build a foundation for pain-free activity, so that those triggers no longer result in pain. (He’s also written a popular book, Back Mechanic, which walks readers through his process — an approach based on decades of research at his spine biomechanics lab and clinic at the University of Waterloo.)

McGill has a set of spine-stabilizing exercises — the McGill Big Three, which Ramin does daily — based on research in his lab that are targeted at people with chronic back pain.

It can be difficult to find someone with the expertise of a back whisperer like McGill, and their time can also be costly. There’s also no study that brings together research on these folks, but if you can find a good one who works for you, your back pain could be improved.

We’re learning how much back pain is mental, and that mind-body approaches can help

So where does physical therapy — usually a combination of guided exercises, mobilization, superficial heat or cold, and health advice — fit into the back pain treatment picture?

In AHRQ’s read of the evidence, it didn’t seem to work better than simple advice to remain active when it came to reducing pain and improving function. (The researchers I talked to said this lack of effect may be because of the variability in physiotherapy approaches and programs, and the difficulty in coming to clear conclusions about the variety of programs on offer.)

Nowadays, though, there are also several different kinds of physical therapies that also integrate psychotherapy or cognitive behavioral therapy, often called multidisciplinary rehabilitation.

Multidisciplinary rehab takes the “biopsychosocial” view of back pain — again, that the pain arises from the interplay of physical, psychological, and social factors. It can of course be tricky to disentangle whether mood disorders like anxiety or depression contribute to people’s pain, or whether they arise out of the pain, but either way, the biopsychosocial model views the physical as only one part of the equation. So these practitioners deal with what’s going on inside the head as part of their back pain therapy — helping patients get treatment for their depression or anxiety, or guiding them through cognitive behavioral therapy to improve their coping skills.

Perhaps not surprisingly, multidisciplinary therapy appears to work slightly better thanphysical therapy alone for chronic back pain in both the short and long term. Patients who get these more holistic treatments are also more likely to return to work.

Spinal manipulation by chiropractors works about as well as exercise or over-the-counter drugs — with some big caveats

Passive therapies can also play a role in helping people manage back pain, though there’s no silver bullet among them, and their effects also tend to be modest and short-lived. (Again, active approaches to managing back pain should be your first stop.) The research base for these alternative therapies is also generally weak: There’s a lot of variability among the practice styles and programs on offer, even within one category of treatment like massage. It can be difficult to blind the patients to the treatment they are receiving, and the people who seek out particular therapies — acupuncture, massage — are probably more amenable to them, which may bias the results. With that said, here’s what we know.

Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack.

There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.

First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back painfound that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; UpToDate reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.

The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.

“Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.”

As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care.

“Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”

While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.

The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments).

The results on massage are mixed — but it’s also pretty harmless

In general, massage therapists work by manipulating the muscle and soft tissue of the back and body. There are many, many different styles of massage: Swedish, deep tissue, sport, myofascial release, Thai, the list goes on. Massages also vary in how long they last, how much pressure is used, and how frequent sessions are, which makes the evidence for massage pretty difficult to interpret.

But there’s good news here: Massage is pretty harmless, and the researchers who study back pain say the approach makes sense from a pain relief perspective. So it may be worth trying.

According to AHRQ, for subacute (lasting between seven and 12 weeks) and chronic low back pain, massage seems to improve symptoms and function in the short term (i.e., one week) — but there’s no evidence that it leads to any long-term change. At best, you’ll get a bit of immediate relief, but nothing lasting.

The Cochrane systematic review on massage for low back pain looked at 25 trials on massage and, like AHRQ, found short-term improvements in pain and function for both subacute and chronic low back pain but a very mixed evidence base.

Acupuncture seems to help too — sort of — though it’s more controversial

One of the oldest approaches to back pain is acupuncture, a core part of traditional Chinese medicine. The philosophical underpinning of acupuncture is that disease or pain in the body is the result of imbalances between the body’s “yin and yang forces.” “Vital energy circulates throughout the body along the so-called meridians, which have either Yin or Yang characteristics,” the Cochrane authors explain. Using needles to stimulate the parts of the body that are located on these meridians can modulate pain or reverse disease, practitioners claim.

A 2005 Cochrane review looked at the evidence for acupuncture and low back pain and came to a few useful conclusions: There was “insufficient evidence” to make any recommendations about acupuncture for acute low back pain — so it may or may not help people. For chronic pain, acupuncture seemed to offer more pain relief when compared with no treatment or sham acupuncture (when practitioners use needles that don’t actually penetrate the skin). The needling also improved function in the short-term when compared with no treatment for chronic pain sufferers. But acupuncture was not more effective than other treatments.

UpToDate looked at more recent research and noted that the studies on acute pain were still limited, and that evidence for acupuncture’s effects on chronic pain is somewhat conflicting. The review also noted it was unclear whether acupuncture’s benefit lies in the needling, or in the placebo effect.

The author of the Cochrane review, Andrea Furlan, pointed to a more recent randomized trial, which came out in 2009 after her review was published: It also found that acupuncture seemed to reduce chronic low back pain — but it didn’t seem to matter where the needles were placed, raising questions about the meridian philosophy guiding the practice.

This is what makes acupuncture controversial. Science suggests it might work — but the squishiness of the findings, combined with the lack of scientific underpinning in acupuncture’s philosophy, leaves room for interpretation. And evidence-based medicine thinkers and skeptics view the results of studies as suggestive of nothing more than acupuncture’s potent placebo effect.

Researchers have found that the more dramatic the medical intervention, the stronger the placebo effect. And getting poked all over the body by needles is a pretty dramatic intervention. (See this classic study comparing water injections with sugar pills for migraines, as well as Vox’s placebo explainer by Brian Resnick.) That’s not to mention you can never run a double-blind placebo — the gold standard in health research — on acupuncture, since that would involve both practitioners and patients not knowing (or being blinded to) what treatment they are giving and receiving.

We need make our default choices more back- (and health-) friendly

There’s a pretty simple adage public health officials stick to: Make it easy for people to stay healthy, and make it hard for them to get sick.

When it comes to back pain in America, we make it easy for people to get sick and hard for them to stay healthy.

There’s a complete disconnect between what insurance providers will cover for people and what actually helps their back pain. It’s still much easier to get your opioids or back surgery paid for by your insurance provider than to get a massage or exercise program reimbursed.

More states need to move in the direction of places like Oregon, where insurance payers are making the default options for people with back pain healthier by expanding access to, and coverage for, non-drug options.

For example, the Oregon Health Plan (the state’s version of Medicaid, federally funded health insurance for the poor) has ensured that alternatives like acupuncture and physical therapy are covered. It’s also expanded access to treatment for the behavioral health factors that are associated with back pain (such as depression and anxiety) by paying primary care clinics extra to be able to hire behavioral health specialists and meet patients who may not have had access to those services. Finally, it’s opened non-medication pain clinics, where people with low back pain can get a range of treatments as well as help to taper off their opioid prescriptions.

Amit Shah, the chief medical officer at CareOregon (one of the insurance companies administering the Oregon Health Plan), said they decided to move in this direction in the face of the mounting evidence of the harm opioids were causing. “Chronic lower back pain is very prevalent, and we know some people with chronic lower back pain have used opioids for it,” he said. “There’s been a lot of evidence and studies about how opioids are not necessarily the most effective approach, while other medical interventions are effective.”

This knowledge, along with “the continual realization that patients deserve more than a prescription that doesn’t necessarily work,” Shah said, pushed Oregon to experiment with a new benefit structure that might actually help people. “We’re trying to expand the options instead of limiting choice only to opioids.”

Officials in Oregon haven’t yet determined the cost of this new scheme, but opioid prescriptions are already down. Shah also said he’s confident that the measures are bound to reduce the cost burden overall, since alleviating pain can help people can get back to work and bring down the numbers of opioid deaths. If only other states would follow Oregon and take back pain this seriously.

*A note on the methods for this installment of Show Me the Evidence

There’s a mountain of research on low back pain. (Entering the term in the PubMed search engine turned up more than 31,000 results.) So I zeroed in on the highest-quality evidence: systematic reviews. (These are syntheses of the research evidence that bring together all the highest-quality studies to come to more fully supported conclusions.)

I found the Agency for Healthcare Research and Quality (AHRQ), a federal agency that crunches the best available data on the effectiveness of health care interventions and had recently (February 2016) published a comprehensive 800-page systematic review of research on noninvasive treatments for low back pain. The AHRQ review covered 156 of the best back pain studies from 2008 to April 2015. I then searched for low back pain–related systematic reviews on PubMed Health, the government search engine that specializes in systematic reviews and meta-analyses, to cover the recent period left out of the AHRQ review (from May 2015 to the present, July 2017).

To make sure I wasn’t missing anything, I consulted the chronic and acute low back pain articles on UpToDate, (a service that synthesizes the best available research for clinicians), the Cochrane Library of systematic reviews, and guidelines.gov, and sometimes followed the footnotes in these reviews to other studies. Ramin’s book Crookedwas also an excellent source for thinking on back pain. Finally, I conducted interviews with nine back pain doctors and researchers, including authors of many of the systematic reviews referenced here.

My conclusion agrees with the February 2017, report by the American College of Physicians.